Keto Flu

When first starting a ketogenic diet, some people experience the “keto flu”— a cluster of symptoms that may include muscle cramps, headaches, fatigue, dizziness, and nausea. Dehydration, electrolyte loss, and carbohydrate withdrawal are some of the main causes of keto flu. Increasing water intake, avoiding strenuous exercise, getting adequate sleep, and eating enough fat while cutting out carbs slowly can ease your transition into keto and help you avoid the keto flu. Adding the following supplements can also help alleviate keto-flu symptoms.

Electrolytes

Electrolytes, such as potassium and sodium, can be depleted on a ketogenic diet. This is because restriction of carbohydrates reduces insulin levels, which causes the kidneys to excrete sodium from the body. Keto diets also eliminate many potassium-rich foods like fruits, beans, and starchy vegetables. Both potassium and sodium are needed for regulating fluid balance and muscle and nerve function. Adding magnesium can help ease muscle cramps and headaches and support sleep. In supplements, electrolytes such as potassium and magnesium can be found alone or in combination with sodium as a complex. Aim for 3-5 grams of sodium, 1-3.5 grams of potassium, and 400-600 milligrams of magnesium from food and supplements per day. ¹

Bone Broth

Bone Broth is a keto-friendly food that is a source of naturally occurring electrolytes, particularly sodium and potassium. Incorporate it in a multitude of ways by adding it to keto-friendly soups, sipping it out of a mug, or sautéing your veggies in it. Of note, bone broth is also high in protein, so be sure to count it towards your protein macronutrient goal. Of note, bone broth contains protein, but because it is not a complete protein it does not count towards the total Daily Value for protein on food labels, nor does it impact ketosis, it should also not be relied on as the sole source of protein your diet.²

Ketone Production

There are some supplements that provide ketones directly to the body (exogenous ketones) and others that enhance the body’s own production of ketones (endogenous ketones). By contributing ketones, these supplements can decrease the time it takes to reach ketosis, reduce symptoms of the keto flu, and potentially enhance the benefits of a ketogenic diet, which include increased energy, improved athletic performance, weight loss, and improved cognition, memory, and mood. ²

MCT

MCT, or medium chain triglycerides, are a special class of fats that, once absorbed, head straight to the liver where they are preferentially metabolized to create ketones for energy (i.e., they support endogenous production of ketones). In a study of 28 healthy adults starting a ketogenic diet, the addition of MCT oil (2 tablespoons three times per day for 20 days) led to higher blood ketone levels and a faster time to ketosis compared to controls. Subjects were also less likely to report symptoms of the keto flu.iv The majority of MCT supplements are available as MCT oil. To support bowel tolerance, start with 1 teaspoon per day, eventually working up to 2 tablespoons per serving. MCT oil is best taken with a meal to avoid upset stomach or diarrhea. MCT also comes in powders and capsules, which may be better suited for on-the-go lifestyles. Powders can easily be incorporated into baked goods or added to coffee to give it a creamier texture.

Beta-hydroxybutyrate (BHB)

Beta-hydroxybutyrate (BHB) is the most abundant ketone produced endogenously in the liver.⁵ However, it can also be supplied exogenously through supplements to increase serum BHB levels and promote the beneficial effects of nutritional ketosis.⁶ In supplements, BHB is most often bound to a mineral such as calcium, magnesium, or potassium (also known as ketone salts). For dosing, follow the directions on the label.

Digestion

During a ketogenic diet, the large shift in macronutrient composition may lead to fluctuations in digestion, including gut discomfort, changes in bowel habits and, potentially, disruption of the balance of bugs inhabiting the gut. The supplements below can all provide additional support to keep your digestive system running smoothly and in tip-top shape.

Fat Digestive Enzymes

Fat Digestive Enzymes can aid fat digestion and absorption. For some, the increase in fat intake on a ketogenic diet may overwhelm the body’s ability to break it down. This is more likely to occur in people first starting a ketogenic diet, individuals with gallbladder problems, or those older in age. In this scenario, digestive issues such as indigestion, gas, bloating, or loose stools can arise. To help combat this, consider adding a digestive enzyme supplement that contains a high amount of lipase, the primary enzyme that breaks down fat, and ox bile, which helps to emulsify and prepare fat for absorption. Follow the directions on the bottle and be sure to take enzymes right before or right as you start eating.

Magnesium

Magnesium can support bowel regularity and motility in case of constipation. Because the ketogenic diet is typically lower in fiber-containing foods, constipation is more likely to occur. In this scenario, opt for liquid or powdered magnesium supplements where magnesium is bound to oxide or citrate. It is these forms that, in higher doses, can have bowel loosening effects. For dosing, follow the directions on the label.

Fiber

Fiber supplements providing both soluble and insoluble fiber can aid digestion and promote regularity and elimination. Together, insoluble and soluble fiber increase the weight and size of the stool and soften it, making it easier to pass. Common sources of fiber include, but are not limited to, psyllium, flax, apple, oat, chia, and hemp. Aim for 20-35 grams of fiber per day. The best way to increase fiber in your diet is to add a little more each day, slowly building up to the recommended levels. With added fiber, it is important to drink plenty of clean water—at least half your body weight (in pounds) in ounces per day.

Probiotics

Probiotics contribute beneficial bacteria to our gut, which are needed to support the normal functioning of our digestive tract, including digestion and absorption, elimination, and synthesis of important nutrients. Look for a multi-strain probiotic containing Lactobacilli and Bifidobacterium species.

Prebiotics

Prebiotics are specific types of dietary fiber that feed the beneficial microbes already in the gut. By nourishing our good gut bugs, prebiotics support bowel regularity, enhance digestion, and balance the microbiome. Supplements can be found as prebiotic fiber blends or as inulin, a type of fiber derived from chicory root. Follow dosing recommendations on the label. If bloating or gas occur, then reduce the dosing to half of that on the label and slowly work your way up.

Mitochondrial Health, Energy, & Stress

A primary benefit of a ketogenic diet is supporting the health of our mitochondria—the energy powerhouses of the cell. Specifically, ketosis enhances mitochondrial function and biogenesis (the creation of new mitochondria), resulting in improved metabolic health and energy levels.⁷ However, if you’re experiencing chronic stress, you may not fully realize these benefits and you may continue to battle fatigue, stubborn body fat, and poor metabolic health. To get the most out of keto, consider adding the following supplements to optimize mitochondrial health, energy levels, and/or help you manage chronic stress.

L-Carnitine

L-Carnitine is an amino acid derivative that helps transport fat into our mitochondria so that it can be used for energy. With a keto diet, the shift to using more fat for fuel increases the demand for L-carnitine. This is especially true at the start of the diet, as the need for L-carnitine may exceed the body’s ability to synthesize it.⁸ Providing additional L-carnitine for a time through supplements can support the mitochondria’s use of fat for energy, helping reduce fatigue and aiding the transition to ketosis. The effective daily dose of L-carnitine used in most studies is 2-4 grams.^{9 10} Begin with 500 mg per day for a few days and increase the total amount by the same dosage every few weeks until the desired dose is reached.

CoQ10

CoQ10 is an antioxidant that is essential for producing cellular energy (ATP) within the mitochondria. Without CoQ10, the cell mitochondria cannot function well, and energy production will be reduced, resulting in fatigue. Often, CoQ10 levels become depleted as a result of aging, use of certain medications (such as statins), nutritional deficiencies (B6, for example), and stress.¹¹ In the scientific literature, supplementing with CoQ10 has been shown to decrease fatigue, enhance cognition, and improve exercise performance and recovery.^{12 13} Begin with 100-300 mg per day.

Adaptogens

Adaptogens like ashwagandha, rhodiola, and ginseng help the body adapt to stressors. Each contains unique bioactive compounds that combat mental and physical fatigue, improve sleep, and boost cognition, mood, and energy.^{14 15} For dosing recommendations, refer to our article "Shield Yourself from Stress with Adaptogens"

B Vitamins

B Vitamins are not only necessary for the conversion of fats into energy, but they also support mental well-being and mood and decrease subjective stress levels. A recent meta-analysis found that in 11 out of 18 randomized controlled trials, daily B vitamin supplementation resulted in positive effects on mood, especially related to stress, when compared to a placebo.¹⁶ While each of the B vitamins carries out its own unique functions, they work together to support health, so a high-potency B-complex supplement may be beneficial. 

References

1. Sisson, M. Electrolytes and Keto: Why They Matter for the Transition. Retrieved from https://www.marksdailyapple.com/electrolytes-keto/
2. Sisson, M. (2020, Dec 23). Does bone broth break a fast? MarksDailyApple.com. Retrieved August 21, 2023 from https://www.marksdailyapple.com/does-bone-broth-break-a-fast/
3. Harvey, C., Grant, S., et al. (2018). The use of nutritional supplements to induce ketosis and reduce symptoms associated with keto-induction: a narrative review. PeerJ, 6:e4488. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5858534/pdf/peerj-06-4488.pdf
4. Harvey, C., Schofield, G., et al. (2018). The effect of Medium Chain Triglycerides on Time to Nutritional Ketosis and Symptoms of Keto-Induction in Healthy Adults: A Randomized Controlled Clinical Trial. J Nutr Metab. Retrieved from https://pubmed.ncbi.nlm.nih.gov/29951312/
5. Newman, J., Verdin, E. (2019). B-Hydroxybutyrate, A Signaling Metabolite. Annu Rev Nutr, 37:51-76. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6640868/
6. Harvey, C., Grant, S., et al. (2018). The use of nutritional supplements to induce ketosis and reduce symptoms associated with keto-induction: a narrative review. PeerJ, 6:e4488. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5858534/pdf/peerj-06-4488.pdf
7. Hasan-Olive, M., Lauritzen, K., et al. (2019). A ketogenic diet improves mitochondrial biogenesis and bioenergetics via the PGC1a-SIRT2-UCP2 Axis. Neurochemical Research, 44:22-37. Retrieved from https://link.springer.com/article/10.1007/s11064-018-2588-6
8. Berry-Kravis, E., Booth, G., et al. (2002). Carnitine Levels and the Ketogenic Diet. Epilepsia. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1046/j.1528-1157.2001.18001.x
9. L-Carnitine (2019, Dec). Oregon State University. Retrieved from https://lpi.oregonstate.edu/mic/dietary-factors/L-carnitine#biological-activities
10. Stephens, F., Wall, B., et al. (2013). Skeletal muscle carnitine loading increases energy expenditure, modulates fuel metabolism gene networks and prevents body fat accumulation in humans. J of Phys, 591:4655-4666. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3784205/
11. Maraver, J., Cordero, M., et al. (2014). Coenzyme Q10 Therapy. Mol Syndromol, 5(3-4):187-197. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4112525/
12. Cooke, M., Iosia, M., et al. (2008). Effects of acute and 14-day coenzyme Q10 supplementation on exercise performance in both trained and untrained individuals. J Int Soc Sports Nutr; 5:8. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2315638/#:~:text=For%20example%2C%20several%20studies%20have,individuals%20%5B12%2D14%5D.
13. Shahidi, M., Komaki, A. (2018). Influence of Chronic Coenzyme Q10 Supplementation on Cognitive function, learning, and memory in healthy and diabetic middle-aged rats. Neuropsychobiology, 77:92-100. Retrieved from https://www.karger.com/Article/Abstract/495520#:~:text=Previous%20reports%20have%20demonstrated%20that,compensated%20for%20by%20its%20supplementation.
14. Liao, L, He, Y., Li, L., et al. (2018). A preliminary review of studies on adaptogens: comparison of their bioactivity in TCM with that of ginseng-like herbs used worldwide. Chin Med, 13:57. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6240259/
15. Panossian, A., Wikman, G. (2010). Effects of adaptogens on the central nervous system and the molecular mechanisms associated with their stress-protective activity. Pharmaceuticals (Basel). 3(1):188-224. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3991026/
16. Young LM, Pipingas A, White DJ, Gauci S, Scholey A. A Systematic Review and Meta-Analysis of B Vitamin Supplementation on Depressive Symptoms, Anxiety, and Stress: Effects on Healthy and ‘At-Risk’ Individuals. Nutrients. 2019; 11(9): 2232. https://pubmed.ncbi.nlm.nih.gov/31527485/